Please review the nominator guildelines and eligibility requirements
Please follow all instructions when completing this nomination form for the IEEE Member and Geographic Activities (MGA) William W. Middleton Award.
All fields are required, unless noted.

Nomination form

Nominee Information

Supply the full name, IEEE membership number, grade, and contact information of the individual being nominated.

Name:
Member Number:
Address:
City:
State/Province:
Postal Code:
Country:
E-mail:
Phone (Home - optional):
Phone (Other - optional):

Achievements and Accomplishments

Current Responsibilities
Indicate nominee's current IEEE responsibilities.

Previous Responsibilities
Indicate nominee's previous IEEE responsibilities.

Length of Service

MGA Goals Met, How Goals Were Met, and Significant Nature of Achievement
Refer to the MGA Goals and Strategies and select the goal(s) met. Explain the achievement(s) which accomplished the listed goal(s). Please explain in concise language what was innovative or significant about the approach or method of achievement. The accomplishments of the candidate should be of "significant performance" and should have made a distinguishing contribution to IEEE and the MGA Board.

Suggested Citation:
The "Suggested Citation" of what will appear on both the plaque and/or the certificate awarded to the recipient(s). The citation should reflect the award criteria and the nominee's achievement.

Endorsements

In addition to the nominator, three IEEE members must endorse this nomination. Please supply the names and IEEE membership numbers of the endorsers.

A letter of endorsement from each of the named endorsers must be submitted. After completing this online nomination form, please e-mail the Letters of Endorsement to MGA Awards.

1. Name:		Member Number:
2. Name:		Member Number:
3. Name:		Member Number:

Nominator Information

As the nominator, supply your full name, IEEE membership number, and contact information.

Name:
Member Number:
Address:
City:
State/Province:
Postal Code:
Country:
E-mail:
Phone (Home - optional):
Phone (Office - optional):

Acknowledgement of Regional Director

The Regional Director should be informed of the nomination, but MGA Board members cannot be nominated for an MGA award, nor may they serve as an endorser or nominator of a candidate.

Additional Comments (optional)

The MGA Awards and Recognition Committee reserves the right to consider any nomination for awards other than the award suggested when, in its opinion, the support and justification may more appropriately apply to other MGA Awards. MGA awards are peer-recognized awards; therefore, self-nomination is not permitted.

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